31 December 2005

I am outraged that there are so many people that cannot get basic health care . . . This should be fixed. I'm afraid though that fixing it may even the playing field, but also somehow lower the quality of the best levels of care. Here is where I'm being selfish. I'm not in that 20% and I have been able to secure incredible care and innovative treatment for my son. . . . we were able to have Nathan operated on by the single most qualified surgeon in the world for the procedure that he needed. Can the system be fixed without removing the framework that allows for such incredibly talented people and innovative care to flurish?

It is quite likely that the talented and innovative folks Luke refers to here flourish in spite of and not because of the current economic structure of medicine. This structure creates many perverse incentives. For example, many of the best physicians stay in academic medicine, which is notorious for the fact that it pays less than private practice, and requires much more personal commitment. The surgeon who operated on Nathan very likely makes less than one with a nice suburban practice who just does a lot of really simple procedures. And the docs have little to no say over how much they can charge for a given procedure -- the fee schedules are dictated by the government and insurance companies. Market forces do not apply -- if you provide a superior service in any respect, there is no ability to command higher compensation. Given that fact, the only way for docs to get ahead financially is to deliver more efficient care -- which translates into hurried encounters with the caregivers and a definite decrease in quality of care.

I don't think a medicare-for-all type system would affect this at all, either for better or for worse. I haven't thought this through fully yet, so the details are sketchy. We would need some method for providing a stratified system. I think it would be a good thing if there were specialists who could command higher fees, and I don't have a problem with practices which cater to rich people, offering more attention and more convenient and personalized services for higher fees. Furthermore, Canada's system, which has many many benefits, has a huge downside: physician compensation is capped by the government, which removes the entrepeneurial incentive and has resulted in an exodus of canadian docs to the US. I would not want to see a similar situation develop here.

This is no surprise. My experience is that our ED group collects about 35 cents on the dollar. What the study does not mention is that the government, via Medicare and Medicaid, reimburses around 30 and 25 cents on the dollar. It also alludes to the fact that we are the only industry in the United States which is obligated by federal law to provide services to any one who requests them, regardless of their ability or willingness to pay. It's a huge unfunded mandate. I have no problem with that policy on a moral basis, but it is a huge liability on the backs of hospitals and physicians.

Of course, it wouldn't be an issue if there was universal health insurance, since everybody who came to the ER would have health coverage. But we don't, so 20% of all our patients are sicker and wind up with huge bills which they can't pay and we write off as "bad debt." And then after we apply the proverbial million-dollar band-aid, they can't get follow-up care. In 1990, there were 6000 ERs and 90 million ER visits. In 2001, there were 110 million ER visits, but only 4000 ERs.

Our health care system is so f*cked. It's an outrage that the richest country in the world can't provide even basic health care to 20% of its population. There's a simple solution, that Bush would never support and too many democrats lack the imagination or courage to propose: Medicare for all. It would have to be supported by premiums and means-tested. A program that big couldn't be viewed as an entitlement or supported solely out of the general fund.

Medicare for all. Three simple words. Who wouldn't jump at it, if it were offered? And it would be so much more efficient than the current system -- the overhead savings alone would go a long way towards paying for the program. And a huge, bloated, inefficient beauracracy (the health insurance industry) would simply cease to exist. Well, that's not entirely true -- some form or supplemental insurance would probably persist -- Medigap and the like. And that's not a bad thing either; I think there is some advantage of some stratification in the health care system. But the administrative cost reduction would be massive, and the tangible benefits inarguable.

I don't know that it is possible in the forseeable future. The medicare drug bill is such a mess, and fixing that and fixing the budget deficit will take years and years. It's hard to imagine Congress taking on such a sweeping health care initiative in the current environment. But something has got to be done, because what we have now is a train wreck. And it's going to get worse.

27 December 2005

Not deep-cover CIA anonymous. But I have decided to take my name off this blog, and any other easily-identifying information. Mostly this is because it occurs to me that if I should blog about my work there is a potential to leave sensitive information out there -- patient info, comments about the hospital or co-workers, etc, and I should at least make a good faith effort to provide some cover of privacy. Furthermore, given my often sardonic "voice" and the somewhat cynical title of the blog, it's probably better if my employer and the hospital at which I work are not readily apparent.

Is this wimpy? 'Cause I don't want to be a wimp.

And it's not like I am going to get fired for voicing my opinion -- I run the group.

But I think it is prudent. I have tried to get all the obvious ID off the site, but as I have noted before, I am not too great with the HTML, so if you notice anything, let me know. I think I will leave my family homepage linked, since family and friends will be the vast majority of my traffic.

25 December 2005

Busy overnight shift. Not many frivolous ED visits last night. Nobody is happy being in the ED at 0400, much less so on Christmas morning. So the stress and bitterness level was higher than usual on the patient side. Not so for the staff. You get a little camaraderie on overnights and moreso on holidays. Unfortunately we were short-staffed nurses, which dampened the festive spirit. But on the other hand, there were no obnoxious drunks, which is a very nice change of pace from the typical overnight shift. Acuity was low and though I saw my 2 patients per hour I admitted none and have had time to sit and blog while on-shift. Now I hope to get out of here on time or early and home before the three-year-old wakes up.

Oh man we are going to have a orgy of materialism. The living room was swamped with presents when I left last night. It's actually more than a little disgusting. We are not expecting the boys to open all their presents in one sitting. I am not sure my attention span would allow it and I am sure the 3-year-old attention span will preclude it. I think we will have a staged present-opening, possibly spread out over several days. Katie (Liza's mother) had the good suggestion of having Eamon round up some of his old toys for donation. I think that's a great idea.

23 December 2005

A tongue-in-cheek algorhythm for choosing a specialty. But very true. Courtesy of the British Medical Journal. A more serious one can be found at the University of Virginia; Emergency Medicine ranked first on my list after taking their quiz.

So Safari is a pretty kick-ass browser on many levels, not least on the visual coolness level. I like it's appearance (I'm a sucker for brushed metal), and it's really easy to use. Despite being a tiny fraction of the browsers in use, it's pretty compatible across most web sites. But apparently, blogger's html editor doesn't work in it.

So I love Safari, but I may have just switched browsers. Though, I have a dual-monitor setup, so I suppose I can just open Firefox for editing my page, and keep using my highly-customized Safari setup for basic browsing.

CORAOPOLIS, Pa. - An emergency room doctor was the central figure in a large OxyContin ring, writing hundreds of fraudulent prescriptions and charging up to $2,000 for each one, authorities said Thursday. [...]

Authorities were tipped to the ring after nurses at Aliquippa Community Hospital got suspicious when patients would come to the emergency room asking for treatment, but would leave if Dr. Alan Egleston wasn't working, the indictment says.

At our ED, we have a serious drug-seeking problem, with Oxys being the current drug of choice. We have some docs who are well known as "candymen" and some who are onsidered "Hardliners." I am definitely among the latter group. Many of the frequent flyers will come and leave if a doc they recognize as a hardliner is working. I've not before heard of an ER doc who aided and abetted the seekers. It's kind of bizarre, really. There's a tension between drug-seekers and ER docs such that it's almost like a betrayal, like he's gone over to the enemy. But it's even more bizarre that a doctor, who spent years training and building a career, and who makes pretty good money working in an ER, would cross over the line into such illegal behavior. How does that happen? Weird.

21 December 2005

Schadenfreunde, as I understand the concept, is a kind of guilty pleasure one takes in contemplating the misfortune of another. Today, I experienced the inverse or perhaps the complementary emotion -- a bit of shame at contemplating my own good fortune.

I'm sure the Germans have a word for that too. They're very into shame.

You might ask why, that is, if anyone were reading this blog which there assuredly is not, but the question remains even if you do not exist to ask it. Well, the Senate passed the Budget Reconciliation bill today. I actually had taken the extraordinary step of calling each and every one of my congresscritters to discuss this bill with them. And while I don't have the clout to get to chat with a congresscritter directly, as a manager of a sizable employer back in the district, I was able to chat directly with their chiefs of staff and/or policy directors. The Reconciliation was important because it contained an important measure to freeze some scheduled cuts in Medicare reimbursement to physicians. All of our representatives and senators are democrats (and it really sucks to be in the minority), and we all agreed that this bill was a moral abomination because it also contained lots of cuts in Medicaid and other programs for society's vulnerable. So we chatted about how they hoped to block passage of this bill, and then perhaps the matter of Medicare and physician's reimbursement could be dealt with separately.

Anyway, the bill passed today, so we get more money, but the poor get screwed.

20 December 2005

No, not the big one. That's not till 2008. Mine. As in the inaugural post. I didn't actually intend to start a blog at all, but I went to post a comment to a friend's blog, about the Bears and the best linebacker since Mike Singletary, and when I went to post the comment it gave me the option of commenting anonymously or logging in and since it was a friend's blog I figured that I should log in since it would be rude to comment anonymously on his blog and I had to choose a username and then it asked me what I wanted to title MY blog since apparently creating your own blog is an intrinsic part of commenting on someone else's blog which makes sense in an odd sort of way. ANYWAY, I hadn't planned on starting my own blog (and I'm still not too committed to the idea so I wouldn't look back here anytime soon) but I started to muse over what I would title a blog if I had one, and so here we are.

Makes perfect sense.

Oh, and the title of the blog might not make sense to you at first, but then remember what I do for a living.

Well, now I am off to comment on Luke's blog. Finally. Let's hope there are no other arcane procedures or initiations into blogger {tm} commenting. Check back here real soon. Really.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

All Content is Copyright of the author, and reproduction is prohibited without permission.